Recommendations for the pharmacologic treatment of acute migraine in children and adolescents focus on the following: (1) the importance of early treatment; (2) selecting the route of administration that is best suited to the features of a particular migraine attack; (3) offering counseling on lifestyle factors that can exacerbate migraine attacks, including avoidance of triggers and overuse of medication. The current guideline is an update of a guideline published in 2004, in which the treatment of migraine in children was discussed. The panel conducted a literature search of articles published between December 2, 2003, and August 25, 2017. Results of the analysis — that is, the current practice guideline summary — were published this year in the journal Headache.1
The investigators sought to provide updated evidence-based recommendations on the acute, symptomatic treatment of migraine in children and adolescents. They aimed to systematically evaluate all randomized controlled trials designed to assess treatments for acute migraine in children and adolescents. The current guideline is intended to answer the following question: “In children and adolescents with migraine, do acute self-administered treatments, compared with placebo, reduce headache pain and associated symptoms (nausea, vomiting, photophobia, and phonophobia) and maintain headache freedom?”1
A multidisciplinary panel was convened by the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology (AAN), which comprised 12 AAN physician members and 3 patient representative members to ensure that the latest guideline was developed according to the procedure described in the 2011 AAN guideline development process manual.2 The panel included randomized controlled trials involving the acute pharmacologic treatment of migraine in children (patients <12 years of age) and adolescents (patients between 12 and 17 years of age). The outcomes assessed were reduction in headache pain and related symptoms at specific periods of time.
In their systematic review of the literature, the members rated the risk for bias of all studies included based on the AAN classification of evidence criteria. The panel developed practice recommendations in which they integrated the findings from the literature review and followed an Institute of Medicine-compliant process to guarantee patient engagement and transparency. All of the recommendations were supported by structured rationales, incorporating evidence from the systemic literature review, related evidence, principles of care, and inferences derived from the evidence.
Among 2482 abstracts chosen by the investigators as being relevant to acute or preventive treatment of pediatric migraine, the researchers reviewed 313 full-text articles and ultimately identified 10 new studies on acute therapy to be included in the current guideline. Of the 10 studies on acute migraine treatment that were included in the 2004 guideline, 6 were included in the current guideline, with the other 4 studies being excluded because they were either class IV studies or had enrolled fewer than 20 participants.
The panel used a modified Grading of Recommendations Assessment, Development and Evaluation process to determine their conclusions.3 They anchored the confidence in the evidence (high, moderate, low, or very low) to the error domain (class of evidence, indirectness of evidence, and precision of effect estimate) with the highest risk for error. This confidence was then upgraded or downgraded by a maximum of 1 level, according to several other domains.
Practice recommendations formulated by the panel were based on the strength of evidence, as well as on additional factors, including axiomatic principles of care, magnitude of the anticipated health benefits relative to the harms, financial burden, availability of the interventions, and patient preferences. Levels of obligation were assigned to the recommendations — A, B, C, U, and R — using a modified Delphi process.2
In summary, results of the study demonstrate that the available evidence supports the use of ibuprofen, acetaminophen (in children and adolescents), and triptans (primarily in adolescents) for the relief of migraine-associated pain, with confidence regarding the evidence varying among the individual agents. High confidence exists that adolescents who are treated with oral sumatriptan/naproxen and zolmitriptan nasal spray are more likely to be headache free at 2 hours compared with those who receive placebo. Although no acute treatments were shown to be effective for migraine-related nausea or vomiting, some of the triptans were effective against migraine-associated phonophobia and photophobia.
Based on their findings, the investigators concluded that patterns of migraine presentation and their associated symptoms in children and adolescents, which often evolve into adult patterns, need to be taken into consideration when designing clinical trials. That all trials of acute treatments in children and adolescents are conducted after proven efficacy has been established in adults may be a contributing factor to the expectation response adding to the placebo effect. This expectation response is widely observed in studies of pain and may help elucidate why such a small number of studies of acute migraine therapy in children and adolescents have reported positive results. Despite the growing body of evidence supporting recommendations for the acute treatment of migraine in the pediatric population, challenges exist. Regardless of which treatment strategy is selected for acute migraine therapy in children and adolescents, treatment plans need to be tailored to the individual patient and his or her family, and must contain education on migraine prevention strategies.
1. Oskoui M, Pringsheim T, Holler-Managan Y, et al. Practice guideline update summary: acute treatment of migraine in children and adolescents. Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Headache. 2019;59(8):1158-1173.
2. Gronseth GS, Woodroffe LM, Getchius TSD. Clinical Practice Guideline Process Manual. 2011 ed. St. Paul, MN: American Academy of Neurology, 2011.
3. Guyatt GH, Oxman AD, Vist GE, et al; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924-926.